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Intraoperative and angiographic images of cerebral aneurysms with complex features, including examples of giant size (A), intraluminal thrombosis (B), complex configuration (C), difficult access location (D), previous treatments (E), calcification of the aneurysm wall (F), embedding on surrounding tissues (G), blister-like aneurysm (H), aneurysm involving parent artery (I), branch arising from aneurysm (J), broad neck (K), and fusiform aneurysm (L). (Reprinted with permission of Mayfield Clinic.)
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Complex intracranial aneurysms (CIAs) include those classified as giant, those located in brain regions of technically difficult access, or that involve arterial trunks/branches, and/or have complicated wall structure. We reviewed retrospectively our management of such lesions in a 12-year period. From 1997 to 2009, 192 patients were admitted with...
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Context 1
... intracranial aneurysms (CIAs) rank high among the most technically demanding neurosurgical pathologies. Although extensive work and effort has been directed to the treatment of these challenging vascular lesions, no formal definition exists on what complex aneurysms are, and it is rather sub- jective to individual interpretation that an aneurysm receives such label. 1–22 However, labeling an aneurysm as complex implicitly means increased risk of a worse outcome in terms of natural history and/or therapy, and increased need for therapeutic skill and expertise for its treatment. Recently, Hanel and Spetzler 6 suggested a definition to include the following attributes to consider an aneurysm as complex: (1) diameter greater than 25 mm; (2) location; (3) previous treatments; (4) presence or absence of collateral circulation; (5) intraluminal thrombus; and (6) calcification of the aneurysmal wall. 6 We have included additional features that warrant the classification of an aneurysm as complex, as depicted in Figure 1 and presented in Table 1. The development of improved strategies for the treatment of CIAs includes skull base approaches, revascularization procedures, improved surgical instrumentation, and anesthetic/postoperative care. Additionally, the more recent introduction of endovascular techniques has endowed us with the ability to push the boundaries of operability of most of these previously inoperable lesions. 2–24 Using the criteria set forth in Table 1 for patient selection, we conducted a retrospective review of prospectively collected clinical data on our management strategies in a 12-year period for patients harboring CIAs at the University of Cincinnati. Using the criteria set forth in Table 1, we retrospectively reviewed prospectively collected data following our 12-year experience of multimodality approach for the treatment of 1332 patients with cerebral aneurysms at the University of Cincinnati. In this series, 1006 patients presented with aneurysmal subarachnoid hemorrhage (SAH) and 326 with unruptured aneurysms from 1997 to 2009. A cohort of 192 patients, representing 9.68% of our total population fit our criteria of CIAs. This group included 131 females and 61 males whose ages averaged 55 years (range 16 to 85 years). In this study population of 192 patients, 128 presented with SAH, representing 12.72% of all SAH patients, and 64 with unruptured, symptomatic CIAs, totaling 19.63% of all unruptured aneurysm patients. Using our database, we compared treatment strategies, treatment-related complications, and outcomes at discharge in both CIAs subgroups (i.e., ruptured and unruptured) respective to those in their subgroups from the total population. For the treatment of complex cerebral aneurysms, this stage was, in our opinion, as important as the treatment procedure itself. At this juncture, ancillary imaging modalities added valuable information for a successful procedure. Unenhanced computed tomography (CT) was used when necessary to assess for calcium deposition on the aneurysm or parent arteries, bone erosion, or pneumatization of the anterior clinoid process. Magnetic resonance imaging (MRI) provided valuable information regarding the relationship of the aneurysm with the surrounding anatomy, the presence of intraluminal thrombus, intrawall hemorrhage, perilesional edema, embolism and its possible time frame, and the occur- rence of subarachnoid hemorrhage (SAH) in cases when minor aneurysmal leakage was suspected. CT angiography (CTA) provided superior three-dimensional (3-D) resolution, and allowed for image manipulation to al- most replicate surgical views. The same applied to rota- tional digital subtraction angiography with 3-D reconstruction, allowing for clear visualization of the aneurysm, its neck, the parent artery, and the origin and trajectory of nearby arterial branches. Strategies for which treatment (or part of it) contemplated therapeutic parent artery occlusion a balloon occlusion test, with or without cerebral blood flow (CBF) studies, was always employed to ascertain the blood reserve through collateral flow, and thus the need for bypass surgery. At the University of Cincinnati, a test protocol for temporary balloon occlusion (TBO) has been developed for patients with anterior-circulation aneurysms that may require carotid ligation due to the antici- pated complexity of the lesion that would preclude parent vessel salvage or remodeling by direct clipping (Fig. 2). Evaluation of collateral flow was performed by selective angiography. After pharmacologic reduction of the mean arterial pressure by 25 to 30%, the patient then underwent continuous clinical neurologic testing. Technetium hexylmethylpropylene amineoxine (TcHMPAO), single- photon emission CT (SPECT) imaging, or xenon- enhanced CT was performed to assess asymmetry in CBF during TBO. An extracranial-intracranial (EC- IC) arterial bypass was recommended for patients in whom TBO fails, those with asymmetry on the SPECT scan, or those with CBF less than 30 cc/100 g/min. 25 Once all necessary testing was complete, the results were analyzed by a multidisciplinary neurovascular team. Recently published data suggest that this approach is associated with better outcomes. 2,5,8–11,24,26–29 As with any other cerebrovascular lesion prone to rupture or that has ruptured already, the goal of therapy is exclusion of the aneurysm from the cerebral circulation with preservation of the blood flow in the neural tissues supplied by the parent vessel and its branches, without disrupting the adjacent brain parenchyma. To accom- plish this goal, all possible approaches should be considered, either as a sole or a combined modality strategy, which may require one or multiple stages. The availability of a multispecialty team, which includes such resources as neuro-otology, specialized neuroanesthesia, vascular surgery, and interventional neuroradiology are key to plan a treatment without logistic restrictions. The same applies to ...
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Background
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Background
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Citations
... Установлено, что значительная часть параклиноидных аневризм (ПклА) может быть отнесена к категории «сложных» по критериям N. Andaluz и соавт. [4], причем сразу по нескольким критериям. И это означает, что их радикальное выключение может представлять технические трудности не только для микрохирургических, но и внутрисосудистых вмешательств. ...
There is a clear trend towards an increase in the number of endovascular interventions for cerebral aneurysms; however, open surgery remains the method of choice for some patients with ruptured and complex aneurysms. For example, the best treatment method for aneurysms of the ophthalmic segment of the internal carotid artery (ICA) is still up to debate. A large number of publications on surgical treatment of carotid-ophthalmic aneurysms do not give clear guidelines in which cases microsurgical or endovascular techniques should be used. There are no Russian papers comparing the results of open and endovascular surgery depending on the clinical course of the disease. We analyze problems of microsurgical treatment of carotid-ophthalmic aneurysms and present data on epidemiology, variations in clinical course, topographic and anatomical features of aneurysms of the ophthalmic segment. The article discusses possibilities of modern diagnostic radiology, the choice of surgical approach, the technique of aneurysm dissection, and methods of proximal control of intraoperative bleeding. Numerous classifications of aneurysms of the ophthalmic segment of the ICA were systematized.
... Complex intracranial aneurysms (CIAs) represent a wide group of lesions with de ant vascular architecture, di cult access, or previous treatment intervention. [2][3][4][5] Among the most cited morphological features include a diameter ≥ 25mm, broad neck (≥ 4mm), dome/neck ratio < 2, wall structure (blister-like, fusiform or dissecting), absent collateral circulation, possessing branches at the aneurysm sac, intraluminal thrombus, and calci ed wall. 2,[5][6][7][8] Because of the intricately diseased anatomy and poor natural history, treating CIAs is often a multifaceted endeavor. ...
... [2][3][4][5] Among the most cited morphological features include a diameter ≥ 25mm, broad neck (≥ 4mm), dome/neck ratio < 2, wall structure (blister-like, fusiform or dissecting), absent collateral circulation, possessing branches at the aneurysm sac, intraluminal thrombus, and calci ed wall. 2,[5][6][7][8] Because of the intricately diseased anatomy and poor natural history, treating CIAs is often a multifaceted endeavor. ...
... 2,[7][8][9] Among microsurgical techniques, cerebral revascularization constitutes a technically demanding craft with the potential to provide a de nitive treatment. 5,[10][11][12] Herein, the present case series aims to illustrate the art of bypass surgery in an institution primarily offering microsurgical management of CIAs. ...
Introduction
Complex intracranial aneurysms (CIAs) comprise a subset of lesions with defiant vascular architecture, difficult access, and prior treatment. Surgical management of CIAs is often challenging and demands an assessment on a case-by-case basis. The generational evolution of bypass surgery has offered a long- standing potential for effective cerebral revascularization. Herein, we aim to illustrate a single-center experience treating CIAs.
Methods
The authors conducted a retrospective analysis of clinical records of patients treated with cerebral revascularization techniques at Hospital Nacional Dos de Mayo, Lima, Peru during 2018–2022. Relevant data were collected, including patient history, aneurysm features on imaging, preoperative complications, the intraoperative course, aneurysm occlusion rates, bypass patency, neurological function, and postoperative complications.
Results
Seventeen patients (70.59% female; median age: 53 years) received treatment for 17 CIAs (64.7% saccular; 76.5% ruptured). The most common clinical presentation included loss of consciousness (70.6%) and headaches (58.8%). Microsurgical treatment included first, second, and third-generation bypass techniques. In 47.1% of cases, an anastomosis between the superior temporal artery (STA) and the M3 segment was predominantly used, followed by an A3-A3 bypass (29.4%), STA-M2 bypass (17.6%), and an external carotid artery to M2 bypass (5.9%). Intraoperative aneurysm rupture occurred in 11.8% of cases. Postoperative complications included ischemia (40%), cerebrospinal fluid fistulas (26.7%), and pneumonia (20%). At hospital discharge, the median Glasgow Coma Scale score was 14 (range: 10–15), and 58.2% of patients had a modified Rankin Scale (mRS) score of ≤ 2. At the six-month follow-up, 82.4% of patients had an mRS score ≤ 2, and the morbidity rate was 17.6%.
Conclusion
CIAs represent a wide spectrum of defiant vascular lesions with a poor natural history. Among the long- standing microsurgical techniques, bypass surgery offers the potential for definitive treatment; however, it merits extensive training and manual dexterity. Our case series illustrated the paramount role of cerebral revascularization for CIAs with a critical approach on a case-by-case basis to provide optimal technical success and neurological outcomes.
... Despite new endovascular techniques and advances in microsurgery, the treatment of GA MCA is still a therapeutic challenge, which is additionally often complicated by technical difficulties, such as the fusiform shape, thrombi in the aneurysm sac, atherosclerosis and calcification of the arterial walls, the presence of candelabra or involvement of the M1 segment [20][21]. ...
Giant aneurysms (GA) of middle cerebral artery (MCA) are rare and account for approximately 0.5-4.8% of intracranial artery aneurysms. Early diagnosis of brain GA is critical. Classic digital subtraction angiography (DSA) with the option of three-dimensional rotational angiography remains the “gold standard” in the diagnosis of intracranial aneurysms, including GA. The primary goal of brain GA treatment is to permanently exclude the aneurysm from the circulation while preserving the flow in the candelabra. The secondary goal is to stop the growth of the aneurysm and reduce the ‘mass effect’ symptoms it causes. Despite new endovascular techniques and advances in microsurgery, the treatment of GA MCA is still a therapeutic challenge. There are only a few reports in the literature describing cases of patients diagnosed with GAs of MCA and evaluating various treatment methods. In this article, we present the case of a 78-year-old patient with GA of the right MCA, who underwent effective embolization of the active part of the aneurysm.
... ICCAs are defined by size (diameter > 25 mm), location (intracavernous, transitional, or infra clinoid), and configuration (complicated wall structure, blister aneurysms involving arterial trunks and branches, pseudoaneurysms, intraluminal thrombus, wall calcification, intraluminal thrombus, and parent vessel calcification) (3)(4)(5); complexity also includes a failed previous surgical or endovascular treatment. ...
Objective
Internal carotid complex aneurysms (ICCAs) management is challenging. Ligating the internal carotid artery (ICA) combined with Superficial Temporal Artery-Middle Cerebral Artery (STA-MCA) anastomosis is an effective treatment option. Balloon test occlusion (BTO) assessments for preoperative decision-making are unaffordable in developing countries. This article discusses the study of Willis polygon (WP) segments as an option and suggests a score for decision-making. Herein, we report the outcomes of a series of patients treated for ICCA aneurysms at a single institution.
Methods
From September 2016 to December 2020, we conducted a retrospective cohort study that analyzed data from patients with ICCAs. Among them, 9 patients received treatment involving ICA ligation combined with STA-MCA anastomosis. Partial or total carotid ligation was determined by using the WP score (WPS).
Results
All Patients underwent STA-MCA anastomosis, in addition to total ICA ligation in 7 patients and partial ICA ligation in 2 patients with a WPS of 7 and 5, respectively. Patients with partially ligated carotid arteries were referred to an overseas neurointerventional center 12 months after surgery. As the BTO test was negative, they underwent ICA occlusion by coiling. Postoperative clinical outcomes did not change in 8/9 patients. In 1 patient, we reported a minor parietal stroke; the patient recovered completely after 6 months. Total aneurysm exclusion by thrombosis was achieved in 7/9 patients after total ICA ligation alone and in 2/9 patients after partial ICA ligation combined with coiling.
Conclusions
Limited access to endovascular assessment techniques such as BTO poses challenges in managing ICCAs. The WPS for decision-making appears to be a simple and safe option. In addition to STA-MCA bypass surgery, total or partial ICA ligation may be proposed depending on the WPS. After 12 months, patients with low WPS who underwent partial ICA ligation combined with bypass had postoperative normal BTO.
Introduction
Internal carotid complex aneurysms (ICCAs) are among the most challenging lesions encountered by vascular neurosurgeons. They are known to have a higher risk of morbi-mortality than simple aneurysms,1 and in some cases, neither endovascular coiling nor microsurgical clipping is optimal. Sacrificing the parent artery is a definitive way to exclude aneurysms.2
Generally, the treatment difficulty for these lesions is due to the need for a codified management algorithm explained by anatomical ruggedness, inaccessibility, and extreme complexity. Poor natural history is associated with a high incidence of complications. Consequently, considerable expertise is required.
ICCAs are defined by size (diameter >25 mm), location (intracavernous, transitional, or infraclinoid), and configuration (complicated wall structure, blister aneurysms involving arterial trunks and branches, pseudoaneurysms, intraluminal thrombus, wall calcification, intraluminal thrombus, and parent vessel calcification)3, 4, 5; complexity also includes a failed previous surgical or endovascular treatment.
As the primary referral center for the neurovascular surgery department in the country, we reviewed our experience in treating ICCAs among 780 treated brain aneurysms. This review is especially relevant given the limited availability of interventional neuroradiologists and endovascular skills. The patients were waiting more than 18 months to benefit from a foreign neurointerventional center supported by the National Health Insurance.
The surgical treatment proposed is an internal carotid artery (ICA) ligation associated with a superficial temporal artery (STA) to the middle cerebral artery (MCA) anastomosis for all symptomatic patients.
Owing to the lack of balloon test occlusion (BTO), ICA ligation, either total or partial, was guided by Willis's polygon study using Angio Computerized Tomography (CT)/MR Tridimensional (3D) reconstruction sequences. Furthermore, we proposed the Willis Polygon (WP) score (WPS), which guides safe internal ligation surgical strategies.
We reported the clinical data of 9 patients diagnosed with ICCAs aneurysms and summarized the treatment effectiveness and experience of ICA ligation combined with low-flow anastomosis.
Four detailed illustrative cases show different examples of ICCAs management: previously coiled, giant, intracavernous, and a combination of surgical treatment and endovascular interventions.
To our knowledge, this is the first study to report such cases and techniques in a developing country.
Section snippets
Patients
From September 2016 to December 2020, 16 complex aneurysms were treated with STA-MCA anastomosis associated with ligation of the parent artery for the middle cerebral location in 7 cases and Hunterian ligation of the ICA in 9 patients.
Patients diagnosed with giant, thrombosed, or complex aneurysms were referred to us by the Commission of National Health Insurance. We had to determine whether the patient could wait (an average of 12–18 months) for an abroad endovascular treatment procedure or
Result
Nine patients underwent ICCAs treatment during the study period. The cases numbered 1 to 9, with different characteristic features shown in Table 1. The pooled study features are presented in Table 2.
Analysis of the epidemiological data showed 3 men and 6 women with an average age of 43 years.
Our patient selection for surgery included only those with symptoms. All 9 patients had headaches; seven, three, and 1 experienced visual deficit, third nerve palsy, and seizure, respectively.
The
Discussion
In developed countries, ICCA management involves a combination of microneurosurgery and interventional neuroradiology; however, situations arise wherein solutions are not achieved. Therefore, indirect exclusion by thrombosis of the aneurysm was proposed, and parental artery occlusion was combined with an extra-intracranial revascularization technique. Wanebo et al.6 advocated low-flow bypass for all patients who were candidates for ICA ligation.
In general, decision-making begins with a brain
Conclusion
Surgical management of ICCAs is challenging, especially in developing countries. Owing to the lack of BTO, the surgical strategy consisted of indirect aneurysm exclusion by total or partial ICA ligation. The WPS was used to guide the procedure. To ensure adequate brain perfusion, STA-MCA anastomosis was performed.
... They found that 192 patients were admitted with CIAs, 128 of whom presented with SAH, while 64 had unruptured, symptomatic CIAs. Treatment included direct clipping (65.6%), endovascular management (coiling/stenting) (28.1%), bypass (3.1%), and no intervention (3.1%) (1) . Their study concluded that a multidisciplinary approach strongly enhances the treatment and handling of possible postoperative sequela of complex aneurysms, an entity initially considered untreatable (1) . ...
... Treatment included direct clipping (65.6%), endovascular management (coiling/stenting) (28.1%), bypass (3.1%), and no intervention (3.1%) (1) . Their study concluded that a multidisciplinary approach strongly enhances the treatment and handling of possible postoperative sequela of complex aneurysms, an entity initially considered untreatable (1) . ...
... Проблема усугубляется, когда помимо огромных размеров имеются другие сложные для хирургии характеристики аневризмы: фузиформное строение, внутриполостное тромбирование, склерозированные или кальцинированные стенки, отхождение ветвей от купола аневризмы, локализация в области М1-сегмента и пр. [6][7][8]. ...
... Значимым фактором риска послеоперационных ишемических расстройств выступает частичное тромбирование полости аневризм [7,8]. У наших пациентов с гигантскими аневризмами СМА мы наблюдали тромбы в большинстве случаев (80%). ...
Background: Surgical treatment of middle cerebral artery (MCA) giant aneurysms is a challenging task. The information on its current principles is rather limited, with the publications based on isolated case reports and small series.
Aim: To identify the types of procedures and evaluate the results of surgery in patients with giant MCA aneurysms.
Materials and methods: We retrospectively analyzed the data on 55 patients who had undergone surgery for MCA giant aneurysms in the Burdenko Neurosurgery Center from 2010 to 2021. Thereafter 52 patients were followed up for 6 to 120 months (for 53.1 33.7 months on average).
Results: The giant MCA aneurysms were located at the M1 segment bifurcation in 33 (60%) patients, within the M1 segment, in 11 (20%), M2 in 7 (12.7%), and M3 and M4 in 4 (7.3%) patients. There were 32 (58.2%) saccular and 23 (41.8%) fusiform aneurysms. Surgical interventions for MCA giant aneurysms included their neck clipping (50.9%, n = 28), clipping with formation of the arterial lumen (3.6%, n = 2), bypass procedures (34.5%, n = 19), wrapping (3.6%, n = 2), and endovascular procedures (7.3%, n = 4). Perioperative worsening of the neurologic status (The Modified Rankin Scale, mRS) was observed in 50.9% (n = 28) of the patients, and the death rate was 1.8% (n = 1). The complete closure of giant aneurysms was achieved in 78.2% (n = 43) of the cases. The long-term outcome was favorable in 76.9% of the patients (40 from 52 available for the follow up).
Conclusion: Microsurgical clipping and bypass types of surgery were the most common surgical procedures for the treatment of MCA giant aneurysms. These procedures are technically complex and are associated with a relatively high number of complications. The main directions of future studies could be in the search for new and more precise diagnostic assessment of the collateral circulation in the cortical MCA branches, improvement of the algorithm for the bypass selection, as well as an investigation of the long-term results of endovascular and combined treatments. A thorough long-term postoperative patient follow-up and the possibility of high quality control angiography are of major importance.
... In these cases, different approaches may be considered. In particular, a bypass strategy could be used to protect one or more cerebral territories distal to the aneurysm that can be secondarily completely or partially occluded through a surgical or endovascular approach [13][14][15][16][17][18][19]. This strategy should be tailored to the specific patient's anatomy and aneurysm characteristics [20]. ...
Despite the increasing popularity of flow diverters (FDs) as an endovascular option for intracranial aneurysms, the treatment of complex aneurysms still represents a challenge. Combined strategies using a flow-preservation bypass could be considered in selected cases. In this study, we retrospectively reviewed our series of patients with complex intracranial aneurysms submitted to bypass. From January 2015 to May 2022, 23 patients were selected. We identified 11 cases (47.8%) of MCA, 6 cases (26.1%) of ACA and 6 cases (26.1%) of ICA aneurysms. The mean maximal diameter was 22.73 ± 12.16 mm, 8 were considered as giant, 9 were fusiform, 8 presented intraluminal thrombosis, 10 presented wall calcification, and 18 involved major branches or perforating arteries. Twenty-five bypass procedures were performed in 23 patients (two EC–IC bypasses with radial artery graft, seventeen single- or double-barrel STA–MCA bypasses and six IC–IC bypasses in anterior cerebral arteries). The long-term bypass patency rate was 94.5%, and the total aneurysm exclusion was 95.6%, with a mean follow-up of 28 months. Median KPS values at last follow-up was 90, and a favorable outcome (KPS ≥ 70 and mRS ≤ 2) was obtained in 87% of the cases. The use of bypass techniques represents, in selected cases, a valid therapeutic option in the management of complex anterior circulation aneurysms when a simpler direct approach, including the use of FD, is considered not feasible.
... Coiling represents the standard procedure to occlude ruptured intracranial aneurysms, given safety and effectiveness in preventing rebleeding and acceptable complication rates [1,2]. In some cases, mainly due to unfavorable anatomy, coiling may be difficult and/or risky (small aneurysms, unfavorable neck, unfavorable angulation [3,4] or ineffective blister-like aneurysms and dissecting aneurysms) [5]. In these cases, alternative treatments have been proposed, including balloon remodeling technique [6], stent-assisted coiling [4], and intrasaccular devices [7]. ...
Purpose
Flow diversion changed the approach to complex intracranial aneurysms, leading to a widespread use and a rapid technological evolution. Indeed, indications continued to expand, including ruptured intracranial aneurysms in selected cases. Recently, new devices have been designed specifically to target smaller vessels. Therefore, we conducted a multicenter study to evaluate clinical outcome, complications, and occlusion rate of patients with ruptured aneurysms treated with new generation low profile Silk Vista Baby (SVB) flow diverter stent (FD).
Methods
We performed a retrospective observational study on consecutive patients who underwent treatment with SVB for ruptured aneurysms at 12 Italian centers. Primary end point was favorable clinical outcome rate, defined as modified ranking score (mRS) of 0–2 at the 3 months. Secondary outcomes were complication rate, aneurysm re-rupture, and complete aneurysm occlusion at last radiological follow-up.
Results
Twenty-five patients were included; at 3 months’ follow-up, 19 patients (79.1%) had favorable clinical outcome (mRS 0–2). Three patients (12.5%) died during follow-up. In-stent thrombosis occurred in two cases (8.3%), managed with glycoprotein IIb/IIIA and intra-stent angioplasty, without clinical consequences. In 18 (85.7%) patients, complete occlusion at 3 months was demonstrated. No rebleeding occurred during follow-up. Presentation with unfavorable World Federation of Neurosurgical Societies grading system (WFNS) and posterior circulation location were both significantly correlated with unfavorable clinical outcome (p = 0.005 and p = 0.02).
Conclusions
Our data suggests that low profile FD treatment of ruptured intracranial aneurysms located distally of the circle of Willis is feasible. New generation low profile FD may represent an alternative option in carefully selected cases.
... Complex intra-cranial aneurysms include not only giant aneurysms but also smaller aneurysms in difficult sites of the human brain and cranial base. Many other features also play a significant role in defining an aneurysm complexity: the presence or absence of collateral circulation, previous treatments, intraluminal thrombus, and calcification of the aneurysmal wall [4]. ...
Background: About 5 % of the population has intracranial aneurysms, however the majority are asymptomatic and never discovered. Subarachnoid haemorrhage, the most frequent manifestation of aneurysm rupture, is a devastating medical disorder that frequently results in severe neurological impairment or death. The aim of this work was to evaluate the efficacy and safety of our procedures including microsurgical and endovascular techniques used for the management of complex wide neck intracranial aneurysms. Methods: This prospective study was carried out on 50 patients with complex wide neck intra cranial aneurysms. All patients were subjected to neuroimaging (CT Brain, MRI brain, MRV, CT brain angiography and diagnostic angiography) and laboratory investigations (CBC, liver and kidney functions and complete coagulation profile). Results: Remodelling technique was the most common technique used for ruptured aneurysms (14 %) followed by clipping (6%). Regarding 3months follow up, the group who had ruptured aneurysm had lower incidence of occlusion and higher incidence of recanalization. The relationship between technique used and outcome (mRS grade) was significant being better with Coilin + balloon technique followed by flow diversion then Coiling+ stent. Conclusions: Endovascular techniques are better to deal with the complex anatomy of intracranial aneurysms. In case of ruptured aneurysm, the earlier the treatment, the better the outcome by preventing the hazards of rebleeding and safe management of vasospasm. CT Brain Angiography with 3D reconstruction proved to be a fast and reliable method for diagnosis and preoperative planning for cerebral aneurysms.
... The successful management of a MCA aneurysm requires considerable expertise on the part of the interventional neuroradiologist together with the use of state-of-the-art techniques and equipment [14] . The morphology of the neck of the aneurysm is the most important feature of an aneurysm in terms of achieving the complete exclusion of the lesion without damaging brain blood flow [15][16][17][18][19][20][21][22] . ...
